Cumberland_Well Abandonment_20230915 (15)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor Information: WELL ABANDONMENT DETAILS
Jonathan Kamionka
7a.Number of wells being abandoned:
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non=water supply wells ONLY with the same
constructionlabandonment,you can szzbmit one form.
3465-A
NC Well Contractor Certification Number 7b.Approximate volume of w�ter remaining in well(s): 40 (gal.)
Blll's Well Drilling Co. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant useJ HTH
2.Well Construction Permit#: j
List all applicable well construction permits(i.e.County,State,Variance,etc.)iflmown 7d.Amount of disinfectant used• 1 lbs
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout i El Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑hri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 350lbs bentonite
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description;of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer removed pump I.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
_Measured depth of well and SWL
(s)abandoned: 3-14-23
well 4.Date . �:, °�r� p�infected well
5a.Well location: SEP 1 ; 2022fiI1ed to top with bentonite
T A Loving Company
.•.a.�.•�in., :Jrnr.ceq is � I
Facility/Owner Name Facility ID#(if appli tl'trficatlon:
7155 Stoney Point Rd, Fayetteville, NC l 3-14-23
Physical Address,City,and Zip Signatufe of Certified Well Contractor or Well Owner Date
Cumberland
By signing this form, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02G.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply
wells ONLY with the same constructionlabandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID# abandonment to the following:
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Division of Water Quality,Information Processing Unit,
6b.Total well depth: 68 ([t) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
4above, also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
20 Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Servicelc6nter,Raleigh,NC 27699-1636
loc.For Water Supply&Iniection Wells: In addition to sending the form to
6e.Outer casing length(if known): (f0 the address(es) above, also submit one copy of this form within 30 days of
completion of well abandonment!to the county health department of the county
6E Inner casing/tubing length(if known): (ft.)
where abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013